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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3643_Библиотеки_им_академика_М_И_Перельмана.pdf
245
NASCET = (A-B)/A
ECST = ( C-B ) / C
CC = ( D-B) / D
A
B
C
D
ECA
ICA
CCA
Fig. 11.1 Comparison between
the various methods of stenosis
measurement. The zone of
stenosis (the tightest area) is
measured against the common
carotid, the internal carotid
(distal to the stenotic lesion), or
the estimated width at the level of
the carotid bulb. The ECST
measurement underestimates the
degree of stenosis. For further
limits and critics of these
methods, see Fig.
11.2
Image Gallery
11 Carotid Endarterectomy
246
a
b
H. Muresian
247
c
Fig. 11.2 (continued)
Fig. 11.2 Limits and precautions for stenosis evaluation. Panel ( a ):
two types of stenoses are presented. Two stenoses with almost normal
arterial caliber in between ( left panel, white arrows ) and long, almost
tubular-like stenosis ( right panel, white arrows ). From the pure mor-
phologic point of view, it is diffi cult to estimate the severity and the
clinical signifi cance of the lesion. Ultrasound may miss the impact on
fl ow of the more distal stenoses. 1–6 = spinous processes of the cervical vertebrae one through six. Panel ( b) : difference in the shape of
stenosis. A fusiform stenosis is presented in the left image, while on
the right, a tubular, stepped stenosis is shown. Although the degree of
stenosis might be similar, the visual perception may be different.
Panel ( c ): stenosis over a hypoplastic ICA ( white arrow ) which makes
diffi cult the correct appreciation of the hemodynamic impact and the
surgical indication. Panel ( d ): stenosis of the ICA + stenosis of the
more proximal CCA ( white arrows ). The stenosis on the CCA appears
frequently as long, eccentric, and apparently not severe. However, the
plaque may depict characteristics of severity (ulceration, rough surface, and increased volume). Endarterectomy performed only at the
level of the origin of the ICA may compromise in time due to the
progressive stenosis of the CCA. A more extended endarterectomy
and longer patch are recommended or stenting of both lesions. Panel
( e ): stenosis at the origin of the ICA with hypoplastic CCA ( white
arrows ). The hemodynamic impact of the ICA stenosis may be diffi cult to appreciate. In cases with an ICA of normal caliber and clinically symptomatic patient, CEA of the bifurcation and graft
replacement of the hypoplastic CCA might represent a valid solution
11 Carotid Endarterectomy
248
d
e
Fig. 11.2 (continued)
H. Muresian
249
CCA
ICA
ECA
a
b
Fig. 11.3 Intracranial stenosis of the ICA and kinking of the cervical
ICA ( white arrows ), precluding the endovascular access. Panel ( a ):
angiographic appearance of the stenosis of the intracranial segment of
the ICA (symptomatic patient) and the extreme kinking of the cervical
portion of the ICA. Panel ( b ): intraoperative aspect, demonstrating the
excess of length of the cervical ICA. The ICA was partially resected (as
with the eversion technique) and reanastomosed to the CCA. Panel ( c ):
completion angiogram, after surgery. The carotid bifurcation appears
enlarged, the kinking was eliminated, and the distal ICA can be easily
accessed ( white arrows ). Panel ( d ): angioplasty and stenting of the
intracranial stenosis of the ICA ( white arrows )
11 Carotid Endarterectomy
250
c
d
Fig. 11.3 (continued)
H. Muresian
251
CCA
ICA
ECA
a
b
c
Fig. 11.4 Simultaneous bilateral carotid endarterectomy in patient
with permanent tracheostomy after laryngectomy for laryngeal cancer – under bilateral cervical block (awake patient). Panel ( a ): prepa-
ration of the patient. Aspect of the tracheostomy. Application of a face
mask for oxygen delivery during the operation. Bilateral cervical
plexus block was applied in this patient. Panel ( b ): intraoperative
aspect of the left carotid bifurcation, prepared for eversion. The ECA
and ICA are disconnected from the CCA. In spite of previous bilateral
neck irradiation, the arterial and periarterial tissues are not diffi cult to
dissect. The IJV and vagus nerve are also easily isolated. Previous
irradiation represents only a relative contraindication for surgery.
Panel ( c ): aspect of the excised plaques from both carotid arteries,
including longer plaques from the CCAs (see also the eversion
technique)
11 Carotid Endarterectomy
252
Fig. 11.5 CEA and direct closure of the arteriotomy. Panel ( a ): prepa-
ration of the carotid bifurcation. Note the placement of the arteriotomy,
at the level of the posterior and lateral portion of the CCA and ICA,
avoiding the nerves of the carotid sinus and glomus. Panel ( b ): excision
of the carotid plaque, in a patient in whom shunting was deployed. Note
the volume of the plaque and the aspect of the remaining carotid wall.
Panel ( c ): operation completed. The image on the left demonstrates a
carotid bifurcation after direct closure of the arteriotomy. Compare with
the shape of the neo-bifurcation obtained with patching ( on the right
side )
ECA
ICA
CCA
a
b
H. Muresian
253
c
Fig. 11.5 (continued)
11 Carotid Endarterectomy
254
Fig. 11.6 Carotid CEA and patch closure. The main steps of the
operation are presented. Panel ( a ): preparation of the carotid bifurca-
tion. Panel ( b ): arteriotomy and identifi cation of the plaque and of
the cleavage plane between the plaque and the remaining arterial
wall. Panel ( c ): removal of the plaque. Panel ( d ): after plaque
removal, note that the remaining arterial interior surface might not
result smooth all around, especially when there is no defi nite cleavage plane around the plaque. Note also that in the distal portion, the
end artery over the ICA appears thicker than the rest. We secure the
ICA end artery with separate stitches, in order to avoid intimal fl aps.
Panel ( e ): insertion of the patch, starting from the distal portion. In
this way, the most important segment of patch closure will be
inspected and any remaining or possible fl aps are resecured. The
entrance into the ICA can be also well calibrated. In cases with a
slender ICA, a curved patch might be more indicated. This can be
obtained from a vascular graft, properly tailored. Panel ( f ): operation
completed. Note the more natural shape of the carotid bifurcation
after patching, as compared with direct closure. Panel ( g ): alterna-
tively, CEA of the origin of the ECA can be additionally performed
and a bifurcated patch can be inserted
a
b
H. Muresian